Leicester Diabetes Centre at University Hospitals of Leicester

Insulin Safety know your insulins! There are many! Humalog® Mix 25 Humalog® Mix 50 Humulin® I Humulin® M 3 Humulin® S Humalog® U-100 Humalog® U-200 Abasaglar ® Actrapid® Insulatard® Levemir® Novo. Mix® 30 Novo. Rapid® Tresiba® U 100 insulin Tresiba® U 200 insulin Xultophy® Lantus® Apidra® Insuman® Basal Insuman® Comb 15 Insuman® Comb 25 Insuman® Comb 50 Insuman® Rapid Toujeo U 300 Hypurin® Bovine Isophane Hypurin® Bovine Lente Hypurin® Bovine Neutral Hypurin® Bovine PZI Hypurin® Porcine 30/70 Hypurin® Porcine Isophane Hypurin® Porcine Neutral © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Intermediate Acting insulin Neutral Protamine Hagedorn ( NPH) Insulatard, Humulin I, & Insuman basal Onset 2 hours Peak 4 -6 hours Duration 8 -14 hours © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Useful in which situations? • Course of steroid therapy where the day time glucose levels rise. Overnight levels are satisfactory. • People that graze throughout the day, small frequent meals. • Can be used once a day in the evening if high fasting reading present Bedtime administration can however lead to nocturnal hypoglycaemia © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Short Acting Insulin Short acting regular human insulin Actrapid, Humulin S, Insuman Rapid • Onset within 30 mins • Peak 2 -4 hours • Duration up to 8 hours © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Insulin Short Acting Soluble Human Insulin – Example: Actrapid, Humulin S, Insuman Rapid Insulin Activity Onset: Within 30 mins Peak: 2 -4 hours Duration: Up to 8 hours 0 6 12 Hours 18 24 8 © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Useful in which situations? • Can be used to address post prandial rises in blood glucose. • When given 20 -30 minutes pre breakfast and evening meal due to the duration of action a lunchtime dose may not be required. • Will address high post evening meal and pre bed blood glucose levels but unlikely to cause a drop in glucose levels overnight. © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Rapid or Quick-acting Insulin Analogues: Prandial (mealtime insulin) Novorapid (aspart), Humalog (lispro), Apidra (glulisine) • Onset less than 15 mins • Peak 50 -90 mins • Duration 2 -5 hours (Faster analogue launched in UK 2017 – Fiasp) © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Rapid Acting Analogue Insulin – Example: Novorapid, Humalog, Apidra Onset: Less than 15 mins Insulin Activity Peak: 50 -90 mins Duration: 2 -5 hours 0 6 12 Hours 18 24 © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Useful in which situations? • To cover post meal rise - inject with food • Can be administered after food if uncertainties around amount of food will be consumed, eg. elderly, children, prison setting. • Duration of rapid acting insulin useful in reducing hypoglycaemia particularly during the night-time. © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Biphasic insulins (Pre-Mixed Insulin) Biphasic Human • Humulin M 3, Insuman comb 15, 25, 50 • Onset within 30 mins • Peak 2 -4 hours • Duration up to 14 hours Analogue Mix • Novomix 30, Humalog mix 25 & 50 • Onset Less than 15 mins • Peak 50 -90 mins • Duration up to 14 hours © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Pre-mixed Human Insulin – Example: Humulin M 3, Insuman Comb 15/25/50 Insulin Activity Onset: Within 30 mins Peak: 2 -4 hours Duration: Up to 14 hours 0 6 12 Hours 18 24 © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Pre-mixed Analogue Insulin Example: Novo. Mix 30, Humalog Mix 25/Mix 50 Insulin Activity Onset: Less than 15 mins Peak: 50 -90 mins Duration: Up to 14 hours Hours 0 6 12 Hours 18 24 © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Useful in which situations? • To cover post meal rise • For people who require prandial cover but only wish to inject twice a day and no more. • Appropriate if patient has regular meal pattern/lifestyle • In certain circumstances mixed insulin can be given once or 3 x a day (need to take into account the profile and individual eating pattern) © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Long Acting Insulin Analogues 1 st generation –Glargine (Lantus) Detemir (Levemir) (Biosimilar lantus = Abasaglar ) Duration- 1 st generation 16 up to 24 hours 2 nd generation – Toujeo (Glargine 300 units) Degludec (Tresiba 100 or 200 units) 2 nd generation 24 up to 42 hours – greater flexibility re injection timing. Onset for long acting analogues approx. 2 hours without a peak © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Long Acting Analogue Insulin – Example: Glargine, Detemir, Toujeo, Degludec* Onset: 2 hours Peak: None Duration: 18 -24 hours Insulin Activity Toujeo lasts longer than 24 hours, degludec can last up to 42 hours 0 6 12 Hours 18 24 © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Useful in which situations? • Where once daily dosing would be beneficial eg. community nurse or carer administration. • When weight gain needs to be minimised. • In those more at risk of admission (flatter profile reduces risk of hypoglycaemia) • Concentrated insulin useful in those requiring large doses. © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.

Recommended reading • www. leicestershirediabetes. org – for local insulin and GLP 1 professional guidelines. 2 nd edition. October 2016 ( currently being updated) Valuable reference resource in respect of prescribing insulin and GLP 1 s • Crasto W, Jarvis J, Davies MJ ( 2016) Handbook of Insulin Therapies. Adis. • Setty SG, Crasto W, Jarvis J, Khunti K, Davies MJ (2016) New insulins and newer insulin regimens: a review of their role in improving glycaemic control in patients with diabetes. BMJ 9 Feb. © Leicester Diabetes Centre at University Hospitals of Leicester NHS Trust, 2018. All rights reserved.